A colleague and I were discussing the importance of documenting massage sessions this morning, so I decided to throw the question out there: How important is documentation?
I can tell you that in my practice, it is extremely important; I have more than a dozen practitioners, and clients may be seen by more than one person. We also file insurance and get a lot of doctor and dentist referrals, and you simply cannot conduct that type of business unless you are willing to keep careful documentation.
On the other hand, I know a lot of lone practitioners who don’t think it’s a big deal at all. I think I’ve mentioned before that I was the administrator at a massage school when licensure came into our state, and there was a grandfather period for people who had documented at least 4 years of practice and 400 documented massages. I couldn’t believe the number of students who called the school to ask, “What do you mean, documented?” My reply was massage that SOAP notes and other pertinenet documents, such as doctor’s prescriptions or other medical information was in the client’s file. I was appalled at the number of people who said, “Oh, that’s all in my head.”
That is totally unprofessional, and in many places, illegal. Most states with a practice act require documentation of sessions, including a statement of informed consent, proof of a privacy notice having been provided, and SOAP notes.
An important thing to remember is that the client file, in many states, belongs to the client. They may walk in the door and request their file, and you are obligated to give it to them. Wouldn’t you feel silly if a client came in, announced that they were moving away and would like to have their file to give to their new therapist, and you had to say you didn’t do any record-keeping? I believe you would.
Keeping good documentation is one of the hallmarks of a professional. What would you think of your physician if he didn’t keep any notes? If you want to be thought of as a health care professional, you have to conduct your practice as one.
Peace & Prosperity,
Laura Allen
August 13th, 2009 at 5:35 pm
Hi Laura,
I will be following you from now on. One of the additional reasons I find SOAP charting important is to show a client their progress over time. It often becomes meaningful to a chronic pain patient when they hear the notes I’ve kept on their improvement. People tend to remember when pain began better than they remember when it went away.
Also, I keep track of injury and illness patterns, which helps them prevent pain and illness and allows them some control.
Take care,
Robin Byler Thomas
RobinsMassageblog.blogspot.com
August 14th, 2009 at 10:03 am
Hi Laura,
I left a comment yesterday but don’t see it posted so forgive me if you get this twice. I agree with your comments on keeping notes for each client. Another reason I keep notes is to show a clients progress over time. They often remember when the pain started but not when there was improvement or when it went away. Also, I find charting helps to find pain patterns; which then helps prevent pain and illness.
Just my two cents, take care,
Robin
August 15th, 2009 at 4:43 am
Thank you Robin. We had an issue with comments for awhile not showing up after they were posted, but it’s fixed now. I appreciate your weighing in.
Laura Allen